Expat_Superior_2011_Part_II

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					TERMS AND CONDITIONS FOR HEALTH INSURANCE OF THE EXPAT SERIES (ME) PART II

EXPAT SUPERIOR TARIFF
  1.    INSURANCE COMPANY:           Emirates Insurance Company (PSC)
  2.    REINSURER:                   HanseMerkur Reiseversicherung AG, Hamburg, Germany
  3.    POLICY HOLDER:               Employees of registered companies
  4.    INSURED INDIVIDUALS:         Policy holders of any nationality and their family members. The maximum age is 65 years. Persons who engage
                                     mostly in physical work also known as Blue-Collar-Work cannot be insured. Spouses and children living together
                                     are regarded as family members.
  5.    INSURANCE CONTRACT:          Terms and conditions of health insurance of the EXPAT Series (ME), part I and part II (EXPAT SUPERIOR tariff).
  6.    AREA OF APPLICATION:         Worldwide excluding USA, Canada, Japan and Singapore. Cover includes 30 days (accumulated) of life threate-
                                     ning emergency cover in the USA, Canada, Japan and Singapore per year. Cover may be extended to worldwide
                                     including USA, Canada, Japan and Singapore at additional premium.
  7.    START OF INSURANCE           The insurance cover commences on the first day of the month applied for, but not before the submission of the
        COVER:                       application at EXPAT Services GmbH Dubai Branch and not before premium payment.
  8.    DURATION OF INSURANCE: 2 months with annual renewal.
  9.    END OF INSURANCE             The insurance policy may be cancelled by the policy holder and the insurance company at the end of each
        COVER:                       2 months period in writing.
 10.    PREMIUM PAYMENTS:            The premium is an annual premium and must be paid before insurance is issued. It becomes due again before
                                     each annual renewal.
 11.    DATA ON INSURED PER-         Health Declaration (Confidential medical history) must be submitted with application. The approval is subject to
        SONS STATE OF HEALTH:        the terms and conditions being fulfilled. Note that insurance company has the right to cancel application (prior or
                                     latter to approval being given) in case that application does not fulfill requirements.
 12.    BENEFITS:                    EXPAT SUPERIOR INSURANCE COVERAGE AS PROVIDED FOR UNDER THIS POINT 2.
 12.1   OUTPATIENT TREATMENT:        00% of invoiced amount for medically necessary outpatient treatment. Please refer to the Insurance Manual for
                                     procedures that require pre-authorisation.
 12.2   INPATIENT TREATMENT:         00% of invoiced amount for medically necessary hospital treatment (including operations, X-rays, radiation
                                     treatment and diagnostics) in approved network facilities (Premium Network) as a private patient in a private
                                     room.
                                     00% of elective out of network treatment is covered, if pre-authorization has been granted. Without pre-author-
                                     ization elective treatment is covered with 75% of comparable costs in U.A.E. facilities. If inpatient treatment has
                                     been received free of charge a cash benefit of AED 90 per night will be paid up to 28 days.
 12.3   PHARMACEUTICALS,             00% of the actual costs if prescribed by a doctor and related to current treatment covered as per the terms and
        BANDAGES AND MEDICINES:      conditions.
 12.4   DENTAL TREATMENT:            80% of invoiced amount for medically necessitated outpatient treatment in simple form with annual limit of
                                     AED 3000 after a waiting period of 6 months.
 12.5   PREVENTIVE CHECKUPS:         Yearly preventive dental checkup. Preventive dental treatment is not covered. Outpatient preventive checkups
                                     (including standard WHO recommended preventive vaccinations) for children up to 5 years of age with yearly
                                     limit of ,000 AED. Yearly outpatient preventive checkup for early recognition of cancerous conditions. The
                                     reimbursement rules for outpatient treatment and dental treatments apply.
 12.6   PREGNANCY AND                Covered after expiry of  months waiting period. Insured must be at least 9 years of age. The reimbursement
        CHILDBIRTH:                  rules of inpatient and outpatient treatment apply. Newborn Cover: Parents must insure newborn within 2 weeks
                                     from birth. Newborn must be insured from date of birth.
 12.7   TOOTH REPLACEMENT AND 80% up to AED 5,000 per year after a waiting period of 2 months for tooth replacement and orthodontic treat
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        ORTHODONTIC TREATMENT: ment for children up to the age of 8 years. Tooth implants are not covered.
 12.8   VISUAL AND ORTHOPAEDIC       00% for bandages, orthopaedic inserts and crutches in simple form. 80% up to AED 500 per year for visual
        AIDS:                        aids (maximum one pair of visual aids per year).




                                                                        
 12.9   OTHER BENEFITS:                   a) 00% of the doctor‘s travel expenses or travel expenses to or from the nearest suitable inpatient treatment if
                                             there is no local doctor available or if the insured person has been certified by a doctor to be unable to walk.
                                          b) 00% of the transport costs to the nearest suitable hospital if medically necessary.
                                          c) For return transport or conveyance to the permanent place of residence, the Insurance Company will reimbur-
                                             se up to AED 22,000 within a continent and up to AED 45,000 between continents. If for the return journey an
                                             authorised ambulance aeroplane should be called for, the restriction to the benefit amount no longer applies.
                                             The most economical means of transport is to be selected for the return journey, so long as this is possible
                                             from the medical perspective.
 12.a   BENEFIT EXCLUSION:                According to terms and conditions of health insurance of the EXPAT Series (ME), part I, § 7 Exclusions. Please
                                          note summary of exclusions below.
 12.b   CLAIMS HANDLING:                  Direct billing in network facilities. Costs related to dental treatment are reimbursed to the insured.
 13.    SUM INSURED:                      Unlimited.
 14.    WAITING PERIOD:                   6 month for dental treatment,  months for pregnancy, 2 months for tooth replacement and orthodontic
                                          treatment.
 15.    YEARLY PREMIUM:                   Please contact ESDB for respective premiums. Please note that the premiums are age and gender dependant.

                                          Premiums may be subject to additional surcharges at yearly renewal. A discount of 7 % may apply for all
                                          premiums in Zone D for exclusion of American Hospital as medical provider. Insured with low claims, as defined
                                          by the Insurance Company, may receive a discount.




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 15.a   DEDUCTIBLE:                       Nil deductible in Zones B, C & D. AED ,00 accumulated per person and year only when elective treatment is
                                          covered in Zone A.
 15.b   CO-INSURANCE:                     20% for visual aids, dental treatment, tooth replacement and orthodontic treatment.

PLEASE SEE INSURANCE MANUAL FOR DETAILED BENEFIT DESCRIPTION AND EXCLUSIONS




EXCLUSIONS
A) PLEASE REFER TO TERMS AND CONDITIONS FOR HEALTH INSURANCE OF THE EXPAT SERIES (ME) PART I, §7, NO. 1
B) LIST OF DEFINED TREATMENTS/BENEFITS NOT COVERED:
  1.    ADDICTIVE CONDITIONS AND DISORDERS
        Treatment / procedures (including cessation or rehabilitation programs) for any condition arising directly or indirectly from abuse or addictive
        conditions and disorders or from any kind of substances or alcohol use ore misuse.
  2.    AGEING AND PUBERTY DISORDERS
        Treatment for symptoms / illness / condition caused be ageing, puberty or other physiological cause and all senility related conditions (for
        instance: osteoporosis, osteopenia, acne, abnormal hair growth etc.).
  3.    ARTIFICAL LIFE MAINTENANCE
        Life support machine is not covered if the use of it will not fully recover or restore the insured’s previous state of well being.
  4.    ARTIFICAL LIMBS
  5.    BIRTH CONTROL MEASURES
        Treatment directly or indirectly arising from or required in connection with male and female birth control including insertion, removal of
        contraceptive devices and all other contraceptives, even if prescribed for any other medical reasons including surgical procedures.
  6.    CANCER - TREATMENT FOR PRE-EXISTING CANCER
  7.    CONFLICT AND DISASTER
        Measures carried out due to disease, illness or injury resulting from nuclear or chemical contamination, war, dispute, revolution, acts of terrorism
        or any similar event like
        - endangering yourselves by entering a known area of conflict,
        - you were an active participant,
        - disregarded your personal safety.
  8.    CONGENITAL CONDITIONS
        Measures for any abnormality, deformity, disease, illness, or injury present at birth whether diagnosed or not.
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  9.    CONVALESCENCE AND ADMISSION FOR GENERAL CARE
        Unless medically necessary, and written consent before receiving the treatment is mandatory.
 10.    CORONARY HEART DISEASES - TREATMENT FOR PRE-EXISTING CORONARY HEART DISEASES



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11.   COSMETIC TREATMENT
      Treatment related to or arising from the removal of non-diseased or surplus or fat tissue whether or not it is needed for medical or psychological
      reasons. Treatment undergone for cosmetic or psychological reasons to improve your appearance / well being or social acceptance. This
      includes, but not limited to:
      - Facelift
      - Weight loss or weight problems
      - Deviated nasal septum
      - Foot care
      - Hair & scalp
      - Gynaecomastia (enlargement of breasts in men)
      - Breast augmentation
12.   DEAFNESS
13.   DEGENERATIVE DISORDERS - MORATORIUM OF FIVE YEARS AFTER POLICY INCEPTION
14.   DEVELOPMENTAL DISORDER
      We do not cover if a child has not attained developmental milestones expected for a child of that age in one or more of the following areas:
      cognitive, physical (including vision and hearing), language (communication), and social-emotional, or adaptive development. Even behavioral
      problems, including attention deficit hyperactivity disorder or problems related to physical development or morphological development.
15.   DONOR ORGANS
      Treatment costs for the following:
      - Transplants involving mechanical / artificial / animal organs.
      - The removal of a donor organ from a donor.
      - The removal of an organ from the insured for purposes of transplantation onto a diseased.
      - The yielding and storage of stem cells to eliminate future possible diseases or illness / umbilical cord blood storage.
      - Cost incurred for the purchase of donor organs.
16.   ELECTIVE/ VOLUNTARY CAESARIAN DELIVERY
17.   EXPERIMENTAL TREATMENT
      Procedures including medication, test, procedures which in our opinion is experimental or has not been proved to be effective, based on the
      conventional medical practice, or which has not been approved as appropriate / effective by any recognized medical body in country of service.
18.   FAMILY DOCTOR TREATMENT
      When insured is treated by spouses, parents, children or persons living together in the immediate domestic circle then costs for materials will
      only be reimbursed if covered by insurance policy.
19.   FOOD SUPPLEMENTS
20.   GENDER TESTING & SCREENING
      Any procedures performed for gender detection / abnormality detection.
21.   GENETIC TESTING
      Procedures done to determine whether or not you or your offspring may be genetically likely to develop a medical condition. Reimbursed if cover-
      ed by insurance policy.
22.   HEALTH HYDROS, NATUROPATHY, RESORTS AND SANATORIUM
      Claims will not be paid for treatments in places appropriate for rehabilitation like spa or health resorts, unless the insured persons lives at this
      place or is forced to stay at this place due to reasons not related to the illness and the treatment.
23.   HEREDITARY CONDITIONS
      Treatment of abnormalities, deformities, diseases, or illnesses that is only present because they have been inherited genetically.
24.   HORMONE REPLACEMENT THERAPY
25.   HAZARDOUS SPORTS ACTIVITIES
      Through professional participation in sporting competitions.
26.   INFERTILITY TREATMENT
      Treatment to assist reproduction, including but not limited IVF. Also treatment required for any child born as a result of medically assisted repro-
      duction or by artificial insemination.
27.   LASIK SURGERY AND ITS COMPLICATIONS INCLUDING THE AFTERCARE
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28.   MENTAL DISTURBANCES
      Treatment for psychiatric illness, mental stress, disharmony, or disorder of the mind and cost of psychotherapist, psychologist, family therapist or
      counselor.




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29.   MIDWIFERY COSTS
30.   OBESITY
31.   ORTHO MOLECULAR TREATMENT
      Orthomolecular medicine describes the practice of preventing and treating disease by providing the body with optimal amounts of substances
      which are natural to the body.
32.   OVER THE COUNTER MEDICATIONS
      Pharmaceutical products or drugs purchased over the counter, not prescribed by a medical doctor or not recognized as medically necessary.
      Specific exclusions are:
      - Non / medicated soaps and shampoos
      - Cosmetic preparations
      - Supplementary medication
      - Supports and non surgical aids
33.   PRE-EXISTING CONDITIONS - UNLESS SPECIFICALLY COVERED UNDER A GROUP PLAN
34.   PREVENTIVE, PROPHYLACTIC AND WELLNESS TREATMENT
      Health screening, Neonatal screening including routine health checks or any preventive treatment is not covered.
35.   RECONSTRUCTIVE OR REMEDIAL SURGERY
      Treatment required restoring your appearance after an illness, or previous surgery or whatsoever, unless:
      - The treatment is a surgical operation to restore your appearance after an accident/disfigurement as a result of any injury if it takes place
        during the policy period.
      - You have obtained our written consent before the commencement of the treatment.
36.   ROUTINE HEALTH CHECK UP
37.   SELF INFLICTED/ MASOCHISTIC INJURIES
      - Treatment for, or arising from, an injury that you have intentionally inflicted on yourselves or for illness caused by terminating treatment early.
      - Claims will not be paid for diseases caused when an insured did not take prescribed protective inoculations.
38.   SEXUAL PROBLEMS, GENDER ISSUES, STERILISATION, IMPOTENCY
      Treatment of any sexual problems like treatment and complications arising from sterilization, sexual dysfunction or impotency (or its reversal).
39.   SEXUALLY TRANSMITTED DISEASES - MORATORIUM OF FIVE YEARS AFTER POLICY INCEPTION
      Treatment for or arising from HIV / AIDS or any other STDs, if your current period of insurance is less than 5 years.
40.   SLEEP DISORDERS
      - Investigations and treatment for snoring, insomnia, sleep apnea or any other sleep related breathing problems.
      - Medications for insufficient sleep or rest.
41.   SURROGATE PARENTING
      Treatment directly related to surrogacy if you act as a surrogate and to anyone else acting as a surrogate for you.
42.   TERRORISM & TERRORIST ATTACK (ONLY ACTIVE PARTICIPATION)
43.   TERMINATION OF PREGNANCY ON NON MEDICAL GROUNDS
44.   TRAVEL EXPENSES FOR MEDICAL TREATMENT
45.   TREATMENT OBTAINED FROM HEALTH CARE PROVIDERS
      who have been excluded from reimbursement by the insurers is not covered, if the party entitled to insurance has been informed of this exclusion
      before treatment.
46.   UNRECOGNISED PHYSICIAN OR FACILITY
      Treatment provided by a medical practitioner who is not recognized by the relevant authorities in the country where the treatment takes place as
      having specialized knowledge, or expertise in the treatment of the disease, illness or injury being treated.
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      Treatment rendered by any one with the same residence as you or who is a member of your immediate family.
47.   VACCINATIONS
      Unless covered through the Expat Superior for children below 5 years of age.




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PREMIUM / COUNTRY ZONES
PLEASE PAY SPECIAL ATTENTION TO THE ZONES BELOW. PERSONS MUST PAY ACCORDING TO THE ZONES IN WHICH THEY ARE
RESIDING. INSURED MUST NOTIFY ESDB OF A CHANGE IN RESIDENCE AS SOON AS IT IS KNOWN.
 ZONE Canada, Japan, Singapore, USA
  A:
 ZONE China, France, Germany, Hong Kong, Israel, United Kingdom
  B:
 ZONE Greece, Guatemala, Honduras, Mexico
  C:
 ZONE Afghanistan, Albania, Alderney, Algeria, American Samoa, Andorra, Angola, Anguilla, Antarctica, Antigua and Barbuda, Argentina, Armenia, Aruba,
  D:  Australia, Austria, Azerbaijan, Azores
      Bahamas, Bahrain, Bangladesh, Barbados, Belarus, Belgium, Belize, Benin, Bermuda, Bhutan, Bolivia, Bosnia and Herzegovina, Botswana, Bouvet
      Island,
      Brazil, British Indian Ocean Territory, Brunei Darussalam, Bulgaria, Burkina Fasco, Burundi
      Cambodia, Cameroon, Canary Island, Cape Verde, Cayman Island, Central African Republic, Chad, Chile, Christmas Island, Cocos (Keeling) Island,
      Colombia, Comoros, Congo, Congo (The democratic Republic), Cook Island, Costa Rica, Cote D’Ivoire, Croatia, Cuba, Cyprus, Czech Republic
      Denmark, Djibouti, Dominica, Dominican Republic
      East Timor, Ecuador, Egypt, El Salvador, Equatorial Guinea, Eritrea, Estonia, Ethiopia
      Falkland Island (Malvinas), Faroe Island, Fiji, Finland, French Guiana, French Polynesia, French Southern Territories
      Gabon, Gambia, Georgia, Ghana, Gibraltar, Greenland, Grenada, Guadeloupe, Guernsey, Guinea, Guniea-Bissau, Guyana
      Haiti, Heard and McDonald Island, Herm, Holy See (Vatican City State), Hungary
      Iceland, India, Indonesia, Iran (Islamic Republic of), Iraq, Ireland, Isle of Man, Italy
      Jamaica, Jersey, Jordan
      Kazakhstan, Kenya, Kiribati, Korea (Democratic Peoples Republic), Korea (Republic of), Kuwait, Kyrgyzstan
      Laos Peoples Democratic Republic, Latvia, Lebanon, Lesotho, Liberia, Libyan Arab Jamahiriya, Liechtenstein, Lithuania, Luxembourg
      Macau, Madagascar, Madeira, Malawi, Malaysia, Maldives, Mali, Malta, Martinique, Mauritania, Mauritius, Mayotte, Micronesia (Federal States),
      Moldovia
      (Republic of), Monaco, Mongolia, Montserrat, Morocco, Mozambique, Myanmar
      Namibia, Nauru, Nepal, Netherlands, Netherlands Antilles, New Caledonia, New Zealand, Nicaragua, Niger, Nigeria, Niue, Norfolk Island, Northern
      Mariana
      Island, Norway
      Oman
      Pakistan, Palau, Panama, Papua New Guinea, Paraguay, Peru, Philippines, Pitcairn, Poland, Portugal, Puerto Rico
      Qatar
      Republic of Macedonia, Reunion, Romania, Russian Federation, Rwanda
      Saint Helena, Saint Kitts and Nevis, Saint Lucia, Saint Pierre and Miquelon, San Mariano, Sao Tome and Principe, Sark, Saudi Arabia, Senegal,
      Seychelles,
      Sierra Lone, Slovakia, Slovenia, Solomon Island, Somalia, South Africa, Spain, Sri Lanka, St. Vincent and the Grenadines, Sth Georgia and Sth
      Sandwich
      Island, Sudan, Suriname, Svalbard and Jan Mayen, Swaziland, Sweden, Switzerland, Syrian Arab Republic
      Taiwan, Tajikistan, Tanzania (United Republic of), Thailand, Togo, Tokelau, Tonga, Trinidad and Tobago, Tunisia, Turkey, Turkmenistan, Turks and
      Caicos
      Island, Tuvalu
      UAE, Uganda, Ukraine, Uruguay, Uzbekistan
      Vanuatu, Venezuela, Vietnam, Virgin Island (British), Virgin Island (US)                                                                           Version: 0.0.20
      Western Sahara
      Yemen, Yugoslavia
      Zambia, Zimbabwe




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